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The impact of COVID-19 on adolescents’ mental health
While the COVID-19 pandemic has impacted the mental health of a wide range of individuals, its adverse effects have been particularly detrimental to adolescents. In this article, I discuss evidence that shows the effects of the pandemic on adolescent patients, potential reasons for this increased distress, and what types of coping mechanisms adolescents have used to counter these effects.
Increases in multiple measures of psychopathology
Multiple online surveys and other studies have documented the pandemic’s impact on younger individuals. In the United States, visits to emergency departments by pediatric patients increased in the months after the first lockdown period.1 Several studies found increased rates of anxiety and depression among adolescents during the COVID-19 pandemic.2,3 In an online survey of 359 children and 3,254 adolescents in China, 22% of respondents reported that they experienced depressive symptoms.3 In an online survey of 1,054 Canadian adolescents, 43% said they were “very concerned” about the pandemic.4 In an online survey of 7,353 adolescents in the United States, 37% reported suicidal ideation during the pandemic compared to 17% in 2017.5 A Chinese study found that smartphone and internet addiction was significantly associated with increased levels of depressive symptoms during the pandemic.3 In a survey in the Philippines, 16.3% of adolescents reported moderate-to-severe psychological impairment during the pandemic; the rates of COVID-19–related anxiety were higher among girls vs boys.6 Alcohol and cannabis use increased among Canadian adolescents during the pandemic, according to an online survey.7 Adolescents with anorexia nervosa reported a 70% increase in poor eating habits and more thoughts associated with eating disorders during the pandemic.8 A Danish study found that children and adolescents newly diagnosed with obsessive-compulsive disorder (OCD) or who had completed treatment exhibited worsening OCD, anxiety, and depressive symptoms during the pandemic.9 An online survey of 6,196 Chinese adolescents found that those with a higher number of pre-pandemic adverse childhood experiences, such as abuse and neglect, had elevated posttraumatic stress symptoms and anxiety during the onset of the pandemic.10
Underlying causes of pandemic-induced distress
Limited social connectedness during the pandemic is a major reason for distress among adolescents. A review of 80 studies found that social isolation and loneliness as a result of social distancing and quarantining were associated with an increased risk of depression, anxiety, suicidal ideation, and self-harm.11 Parents’ stress about the risks of COVID-19 was correlated with worsening mental health in their adolescent children.12 A Chinese study found that the amount of time students spent on smartphones and social media doubled during the pandemic.13 In an online survey of 7,890 Chinese adolescents, greater social media, internet, and smartphone use was associated with increased anxiety and depression.14 This may be in part the result of adolescents spending time reading COVID-related news.
Coping mechanisms to increase well-being
Researchers have identified several positive coping mechanisms adolescents employed during the pandemic. Although some data suggest that increased internet use raises the risk of COVID-related distress, for certain adolescents, using social media to stay connected with friends and relatives was a buffer for feelings of loneliness and might have increased mental well-being.15 Other common coping mechanisms include relying on faith, volunteering, and starting new hobbies.16 During the pandemic, there were higher rates of playing outside and increased physical activity, which correlated with positive mental health outcomes.16 An online survey of 1,040 adolescents found that those who looked to the future optimistically and confidently had a higher health-related quality of life.17
Continuing an emphasis on adolescent well-being
Although data are limited, adolescents can continue to use these coping mechanisms to maintain their well-being, even if COVID-related restrictions are lifted or reimplemented. During these difficult times, it is imperative for adolescents to get the mental health services they need, and for psychiatric clinicians to continue to find avenues to promote resilience and mental wellness among young patients.
1. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health–related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. doi:10.15585/mmwr.mm6945a3
2. Oosterhoff B, Palmer CA, Wilson J, et al. Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: associations with mental and social health. J Adolesc Health. 2020;67(2):179-185. doi:10.1016/j.jadohealth.2020.05.004
3. Duan L, Shao X, Wang Y, et al. An investigation of mental health status of children and adolescents in China during the outbreak of COVID-19. J Affect Disord. 2020;275:112-118. doi:10.1016/j.jad.2020.06.029
4. Ellis WE, Dumas TM, Forbes LM. Physically isolated but socially connected: psychological adjustment and stress among adolescents during the initial COVID-19 crisis. Can J Behav Sci. 2020;52(3):177-187. doi:10.1037/cbs0000215
5. Murata S, Rezeppa T, Thoma B, et al. The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety. 2021;38(2):233-246. doi:10.1002/da.23120
6. Tee ML, Tee CA, Anlacan JP, et al. Psychological impact of COVID-19 pandemic in the Philippines. J Affect Disord. 2020;277:379-391. doi:10.1016/j.jad.2020.08.043
7. Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health. 2020;67(3):354-361. doi:10.1016/j.jadohealth.2020.06.018
8. Schlegl S, Maier J, Meule A, et al. Eating disorders in times of the COVID-19 pandemic—results from an online survey of patients with anorexia nervosa. Int J Eat Disord. 2020;53:1791-1800. doi:10.1002/eat.23374.
9. Nissen JB, Højgaard D, Thomsen PH. The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder. BMC Psychiatry. 2020;20(1):511. doi:10.1186/s12888-020-02905-5
10. Guo J, Fu M, Liu D, et al. Is the psychological impact of exposure to COVID-19 stronger in adolescents with pre-pandemic maltreatment experiences? A survey of rural Chinese adolescents. Child Abuse Negl. 2020;110(Pt 2):104667. doi:10.1016/j.chiabu.2020.104667
11. Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1218-1239.e3. doi:10.1016/j.jaac.2020.05.009
12. Spinelli M, Lionetti F, Setti A, et al. Parenting stress during the COVID-19 outbreak: socioeconomic and environmental risk factors and implications for children emotion regulation. Fam Process. 2021;60(2):639-653. doi:10.1111/famp.12601
13. Chen IH, Chen CY, Pakpour AH, et al. Internet-related behaviors and psychological distress among schoolchildren during COVID-19 school suspension. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1099-1102.e1. doi:10.1016/j.jaac.2020.06.007
14. Li W, Zhang Y, Wang J, et al. Association of home quarantine and mental health among teenagers in Wuhan, China, during the COVID-19 pandemic. JAMA Pediatr. 2021;175(3):313-316. doi:10.1001/jamapediatrics.2020.5499
15. Janssen, LHC, Kullberg, MJ, Verkuil B, et al. Does the COVID-19 pandemic impact parents’ and adolescents’ well-being? An EMA-study on daily affect and parenting. PLoS One. 2020;15(10):e0240962. doi:10.1371/journal.pone.0240962
16. Banati P, Jones N, Youssef S. Intersecting vulnerabilities: the impacts of COVID-19 on the psycho-emotional lives of young people in low- and middle-income countries. Eur J Dev Res. 2020;32(5):1613-1638. doi:10.1057/s41287-020-00325-5
17. Ravens-Sieberer U, Kaman A, Otto C, et al. Mental health and quality of life in children and adolescents during the COVID-19 pandemic—results of the COPSY study. Dtsch Arztebl Int. 2020;117(48):828-829. doi:10.3238/arztebl.2020.0828
While the COVID-19 pandemic has impacted the mental health of a wide range of individuals, its adverse effects have been particularly detrimental to adolescents. In this article, I discuss evidence that shows the effects of the pandemic on adolescent patients, potential reasons for this increased distress, and what types of coping mechanisms adolescents have used to counter these effects.
Increases in multiple measures of psychopathology
Multiple online surveys and other studies have documented the pandemic’s impact on younger individuals. In the United States, visits to emergency departments by pediatric patients increased in the months after the first lockdown period.1 Several studies found increased rates of anxiety and depression among adolescents during the COVID-19 pandemic.2,3 In an online survey of 359 children and 3,254 adolescents in China, 22% of respondents reported that they experienced depressive symptoms.3 In an online survey of 1,054 Canadian adolescents, 43% said they were “very concerned” about the pandemic.4 In an online survey of 7,353 adolescents in the United States, 37% reported suicidal ideation during the pandemic compared to 17% in 2017.5 A Chinese study found that smartphone and internet addiction was significantly associated with increased levels of depressive symptoms during the pandemic.3 In a survey in the Philippines, 16.3% of adolescents reported moderate-to-severe psychological impairment during the pandemic; the rates of COVID-19–related anxiety were higher among girls vs boys.6 Alcohol and cannabis use increased among Canadian adolescents during the pandemic, according to an online survey.7 Adolescents with anorexia nervosa reported a 70% increase in poor eating habits and more thoughts associated with eating disorders during the pandemic.8 A Danish study found that children and adolescents newly diagnosed with obsessive-compulsive disorder (OCD) or who had completed treatment exhibited worsening OCD, anxiety, and depressive symptoms during the pandemic.9 An online survey of 6,196 Chinese adolescents found that those with a higher number of pre-pandemic adverse childhood experiences, such as abuse and neglect, had elevated posttraumatic stress symptoms and anxiety during the onset of the pandemic.10
Underlying causes of pandemic-induced distress
Limited social connectedness during the pandemic is a major reason for distress among adolescents. A review of 80 studies found that social isolation and loneliness as a result of social distancing and quarantining were associated with an increased risk of depression, anxiety, suicidal ideation, and self-harm.11 Parents’ stress about the risks of COVID-19 was correlated with worsening mental health in their adolescent children.12 A Chinese study found that the amount of time students spent on smartphones and social media doubled during the pandemic.13 In an online survey of 7,890 Chinese adolescents, greater social media, internet, and smartphone use was associated with increased anxiety and depression.14 This may be in part the result of adolescents spending time reading COVID-related news.
Coping mechanisms to increase well-being
Researchers have identified several positive coping mechanisms adolescents employed during the pandemic. Although some data suggest that increased internet use raises the risk of COVID-related distress, for certain adolescents, using social media to stay connected with friends and relatives was a buffer for feelings of loneliness and might have increased mental well-being.15 Other common coping mechanisms include relying on faith, volunteering, and starting new hobbies.16 During the pandemic, there were higher rates of playing outside and increased physical activity, which correlated with positive mental health outcomes.16 An online survey of 1,040 adolescents found that those who looked to the future optimistically and confidently had a higher health-related quality of life.17
Continuing an emphasis on adolescent well-being
Although data are limited, adolescents can continue to use these coping mechanisms to maintain their well-being, even if COVID-related restrictions are lifted or reimplemented. During these difficult times, it is imperative for adolescents to get the mental health services they need, and for psychiatric clinicians to continue to find avenues to promote resilience and mental wellness among young patients.
While the COVID-19 pandemic has impacted the mental health of a wide range of individuals, its adverse effects have been particularly detrimental to adolescents. In this article, I discuss evidence that shows the effects of the pandemic on adolescent patients, potential reasons for this increased distress, and what types of coping mechanisms adolescents have used to counter these effects.
Increases in multiple measures of psychopathology
Multiple online surveys and other studies have documented the pandemic’s impact on younger individuals. In the United States, visits to emergency departments by pediatric patients increased in the months after the first lockdown period.1 Several studies found increased rates of anxiety and depression among adolescents during the COVID-19 pandemic.2,3 In an online survey of 359 children and 3,254 adolescents in China, 22% of respondents reported that they experienced depressive symptoms.3 In an online survey of 1,054 Canadian adolescents, 43% said they were “very concerned” about the pandemic.4 In an online survey of 7,353 adolescents in the United States, 37% reported suicidal ideation during the pandemic compared to 17% in 2017.5 A Chinese study found that smartphone and internet addiction was significantly associated with increased levels of depressive symptoms during the pandemic.3 In a survey in the Philippines, 16.3% of adolescents reported moderate-to-severe psychological impairment during the pandemic; the rates of COVID-19–related anxiety were higher among girls vs boys.6 Alcohol and cannabis use increased among Canadian adolescents during the pandemic, according to an online survey.7 Adolescents with anorexia nervosa reported a 70% increase in poor eating habits and more thoughts associated with eating disorders during the pandemic.8 A Danish study found that children and adolescents newly diagnosed with obsessive-compulsive disorder (OCD) or who had completed treatment exhibited worsening OCD, anxiety, and depressive symptoms during the pandemic.9 An online survey of 6,196 Chinese adolescents found that those with a higher number of pre-pandemic adverse childhood experiences, such as abuse and neglect, had elevated posttraumatic stress symptoms and anxiety during the onset of the pandemic.10
Underlying causes of pandemic-induced distress
Limited social connectedness during the pandemic is a major reason for distress among adolescents. A review of 80 studies found that social isolation and loneliness as a result of social distancing and quarantining were associated with an increased risk of depression, anxiety, suicidal ideation, and self-harm.11 Parents’ stress about the risks of COVID-19 was correlated with worsening mental health in their adolescent children.12 A Chinese study found that the amount of time students spent on smartphones and social media doubled during the pandemic.13 In an online survey of 7,890 Chinese adolescents, greater social media, internet, and smartphone use was associated with increased anxiety and depression.14 This may be in part the result of adolescents spending time reading COVID-related news.
Coping mechanisms to increase well-being
Researchers have identified several positive coping mechanisms adolescents employed during the pandemic. Although some data suggest that increased internet use raises the risk of COVID-related distress, for certain adolescents, using social media to stay connected with friends and relatives was a buffer for feelings of loneliness and might have increased mental well-being.15 Other common coping mechanisms include relying on faith, volunteering, and starting new hobbies.16 During the pandemic, there were higher rates of playing outside and increased physical activity, which correlated with positive mental health outcomes.16 An online survey of 1,040 adolescents found that those who looked to the future optimistically and confidently had a higher health-related quality of life.17
Continuing an emphasis on adolescent well-being
Although data are limited, adolescents can continue to use these coping mechanisms to maintain their well-being, even if COVID-related restrictions are lifted or reimplemented. During these difficult times, it is imperative for adolescents to get the mental health services they need, and for psychiatric clinicians to continue to find avenues to promote resilience and mental wellness among young patients.
1. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health–related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. doi:10.15585/mmwr.mm6945a3
2. Oosterhoff B, Palmer CA, Wilson J, et al. Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: associations with mental and social health. J Adolesc Health. 2020;67(2):179-185. doi:10.1016/j.jadohealth.2020.05.004
3. Duan L, Shao X, Wang Y, et al. An investigation of mental health status of children and adolescents in China during the outbreak of COVID-19. J Affect Disord. 2020;275:112-118. doi:10.1016/j.jad.2020.06.029
4. Ellis WE, Dumas TM, Forbes LM. Physically isolated but socially connected: psychological adjustment and stress among adolescents during the initial COVID-19 crisis. Can J Behav Sci. 2020;52(3):177-187. doi:10.1037/cbs0000215
5. Murata S, Rezeppa T, Thoma B, et al. The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety. 2021;38(2):233-246. doi:10.1002/da.23120
6. Tee ML, Tee CA, Anlacan JP, et al. Psychological impact of COVID-19 pandemic in the Philippines. J Affect Disord. 2020;277:379-391. doi:10.1016/j.jad.2020.08.043
7. Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health. 2020;67(3):354-361. doi:10.1016/j.jadohealth.2020.06.018
8. Schlegl S, Maier J, Meule A, et al. Eating disorders in times of the COVID-19 pandemic—results from an online survey of patients with anorexia nervosa. Int J Eat Disord. 2020;53:1791-1800. doi:10.1002/eat.23374.
9. Nissen JB, Højgaard D, Thomsen PH. The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder. BMC Psychiatry. 2020;20(1):511. doi:10.1186/s12888-020-02905-5
10. Guo J, Fu M, Liu D, et al. Is the psychological impact of exposure to COVID-19 stronger in adolescents with pre-pandemic maltreatment experiences? A survey of rural Chinese adolescents. Child Abuse Negl. 2020;110(Pt 2):104667. doi:10.1016/j.chiabu.2020.104667
11. Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1218-1239.e3. doi:10.1016/j.jaac.2020.05.009
12. Spinelli M, Lionetti F, Setti A, et al. Parenting stress during the COVID-19 outbreak: socioeconomic and environmental risk factors and implications for children emotion regulation. Fam Process. 2021;60(2):639-653. doi:10.1111/famp.12601
13. Chen IH, Chen CY, Pakpour AH, et al. Internet-related behaviors and psychological distress among schoolchildren during COVID-19 school suspension. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1099-1102.e1. doi:10.1016/j.jaac.2020.06.007
14. Li W, Zhang Y, Wang J, et al. Association of home quarantine and mental health among teenagers in Wuhan, China, during the COVID-19 pandemic. JAMA Pediatr. 2021;175(3):313-316. doi:10.1001/jamapediatrics.2020.5499
15. Janssen, LHC, Kullberg, MJ, Verkuil B, et al. Does the COVID-19 pandemic impact parents’ and adolescents’ well-being? An EMA-study on daily affect and parenting. PLoS One. 2020;15(10):e0240962. doi:10.1371/journal.pone.0240962
16. Banati P, Jones N, Youssef S. Intersecting vulnerabilities: the impacts of COVID-19 on the psycho-emotional lives of young people in low- and middle-income countries. Eur J Dev Res. 2020;32(5):1613-1638. doi:10.1057/s41287-020-00325-5
17. Ravens-Sieberer U, Kaman A, Otto C, et al. Mental health and quality of life in children and adolescents during the COVID-19 pandemic—results of the COPSY study. Dtsch Arztebl Int. 2020;117(48):828-829. doi:10.3238/arztebl.2020.0828
1. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health–related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. doi:10.15585/mmwr.mm6945a3
2. Oosterhoff B, Palmer CA, Wilson J, et al. Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: associations with mental and social health. J Adolesc Health. 2020;67(2):179-185. doi:10.1016/j.jadohealth.2020.05.004
3. Duan L, Shao X, Wang Y, et al. An investigation of mental health status of children and adolescents in China during the outbreak of COVID-19. J Affect Disord. 2020;275:112-118. doi:10.1016/j.jad.2020.06.029
4. Ellis WE, Dumas TM, Forbes LM. Physically isolated but socially connected: psychological adjustment and stress among adolescents during the initial COVID-19 crisis. Can J Behav Sci. 2020;52(3):177-187. doi:10.1037/cbs0000215
5. Murata S, Rezeppa T, Thoma B, et al. The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety. 2021;38(2):233-246. doi:10.1002/da.23120
6. Tee ML, Tee CA, Anlacan JP, et al. Psychological impact of COVID-19 pandemic in the Philippines. J Affect Disord. 2020;277:379-391. doi:10.1016/j.jad.2020.08.043
7. Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health. 2020;67(3):354-361. doi:10.1016/j.jadohealth.2020.06.018
8. Schlegl S, Maier J, Meule A, et al. Eating disorders in times of the COVID-19 pandemic—results from an online survey of patients with anorexia nervosa. Int J Eat Disord. 2020;53:1791-1800. doi:10.1002/eat.23374.
9. Nissen JB, Højgaard D, Thomsen PH. The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder. BMC Psychiatry. 2020;20(1):511. doi:10.1186/s12888-020-02905-5
10. Guo J, Fu M, Liu D, et al. Is the psychological impact of exposure to COVID-19 stronger in adolescents with pre-pandemic maltreatment experiences? A survey of rural Chinese adolescents. Child Abuse Negl. 2020;110(Pt 2):104667. doi:10.1016/j.chiabu.2020.104667
11. Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1218-1239.e3. doi:10.1016/j.jaac.2020.05.009
12. Spinelli M, Lionetti F, Setti A, et al. Parenting stress during the COVID-19 outbreak: socioeconomic and environmental risk factors and implications for children emotion regulation. Fam Process. 2021;60(2):639-653. doi:10.1111/famp.12601
13. Chen IH, Chen CY, Pakpour AH, et al. Internet-related behaviors and psychological distress among schoolchildren during COVID-19 school suspension. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1099-1102.e1. doi:10.1016/j.jaac.2020.06.007
14. Li W, Zhang Y, Wang J, et al. Association of home quarantine and mental health among teenagers in Wuhan, China, during the COVID-19 pandemic. JAMA Pediatr. 2021;175(3):313-316. doi:10.1001/jamapediatrics.2020.5499
15. Janssen, LHC, Kullberg, MJ, Verkuil B, et al. Does the COVID-19 pandemic impact parents’ and adolescents’ well-being? An EMA-study on daily affect and parenting. PLoS One. 2020;15(10):e0240962. doi:10.1371/journal.pone.0240962
16. Banati P, Jones N, Youssef S. Intersecting vulnerabilities: the impacts of COVID-19 on the psycho-emotional lives of young people in low- and middle-income countries. Eur J Dev Res. 2020;32(5):1613-1638. doi:10.1057/s41287-020-00325-5
17. Ravens-Sieberer U, Kaman A, Otto C, et al. Mental health and quality of life in children and adolescents during the COVID-19 pandemic—results of the COPSY study. Dtsch Arztebl Int. 2020;117(48):828-829. doi:10.3238/arztebl.2020.0828
Caring for Muslim patients who fast during Ramadan
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
